Provider Demographics
NPI:1780374124
Name:DWYER, MALISA SELINA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MALISA
Middle Name:SELINA
Last Name:DWYER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4284 GREAT EGRET WAY
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-8760
Mailing Address - Country:US
Mailing Address - Phone:904-465-6180
Mailing Address - Fax:
Practice Address - Street 1:4284 GREAT EGRET WAY
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8760
Practice Address - Country:US
Practice Address - Phone:904-465-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW214471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical